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03120091 (2) wrI ctTv of cureSION y�CONT"C�TOI2+INFORMATION`-s BUILDING DI VISION � PERMIT ' BUILDING A DDRESS: SAN (JOSE AIR CONDITIONING PERMIT NO03120091 OWNER'S NAME: PERMIT ISSUE DATE NE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 1100 LICENSED CONTRACTOR'S DECLARATION tat Fp I booby afrrm that I am Examined under pmvfsimu of Clore,9(commencing Job Description iU with Section ) fDivision3 fthe Businc cad Professions Code.and my license is jt2W in foufomeawcrrc` . a� �° �0(1) (I(� y REPLACE FURNACE & A/C ? License Class Lica Data tut 1 Cu for S C 'i i, 'i �. Z ty ARCHITEQ'S RATION K a ,�ndcrslanJ myy��pp 1 s hall M used u public recvuds SO. Professional lyA N Liccnscd 5 OWNER BUILDER DECLARATION .�a S I hereby affirm that 1 am exempt from the Cnnlractnis Limm.Law for the u 00 following reoe,(See6un]ID 1.5.Business and Pmfe loin Code:Any city or many I m� which requires a Permit In construct,alter,improve,demnlish,or repairanystructure aaiy prior ha its issuance.also requires the applicant for such permit to File a.signed statement sa that he is licensed pursuant in Sq.FL Floor Area Valuation yr--0 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or y that he is exempt thcrermm and the basis for the alleged exemption.Any violation or Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3��$� 0�3f 0 0 Occupancy not more than firs hundred dolims(SSW). P Y Type ❑Luowner of Ne property.or my employes with wage utheir xle eompensstion, will do the work,and the structure is not intended or offered for sale(Sec.]odd,Business and Professions Cade:The Contractor's Littruc law does not apply to an owner or Required Inspections progeny who builds or improves thereon,and who doessuch work himself or through his own employers,provided that such improvements are not intended or offered for sale If. however,the building or improvement is sold within one year of completion,the owner- builder will new the burden of proving that In,did not build or improve for purpose of sal,.). 0 1.as owner of the property,am eacluively comaning with licensed contractors to construct the pmjccl(Sec.]Gad.Business and Professions Code:)The Contractor's U. _ cc=law docs not apply to an owner of progeny who builds or Improves demon,and who contracts for such projects with a comractor(s)licensed pursuant to the Contractor's ��j[� License lm aw.a[m /r/{� L�n ❑ laept tender P uunnticr Sec. .B C for this rc Owner Date MAY 2 0 2004 WORKERS COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a Certificate or Consent to self-insure for Workers Compcn- sation,as provided for by Section 37W of the Labor Code.for the performance of the �J Blln work for which this permit is issued. 0 I haus and will maintain Worker's Compensation Inemnm,a required by Section 3700 of the labor Code,for the performance of the work for which this permit is issued. y Worker's Compensation Insurance carrier and Policy number aa: CERTIFICATEEXEMPTION FROM WORKERS' COMPENSATION INSURANCE , (Thissectiom necd not M completed if the Permit is for one hundred dollars SIBO) or Los&) 1 certify that in the performance of the work for which this permit is issued.1 shall not employ any p,rain in any manner so ss to become subject to the Worlums Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should become subject to We Worker's Compensation provisions of the Labor Code,you must .JZ fonbwi tb comply with such provisions or this permit Shan be deemed mvoked. ZO CONSTRUCTION LENDING AGENCY (—• . I hemhyafrrm that then isaconstsuction lendingapirmy for the performance of C rIL Le Add.work rod which this permit is issued(Sec.J09],Civ.C.) V] Lender's Name 1< z ndcr'x Adtl , U Q I certify that 1 have read this application and state that the above information is P-r correct.I agree to comply with all city and county ordinances and stale laws coming to U building construction.and hereby noncom reposenmivss of this city to enter upon the above-mentioned property for inspection purposes. F a (We)agree to save,indemnify and keep harmless the Ci ly of Cupertino against h liabilities,judgments.costs and expatriate which may in any way acetic against said City U Z in consequence of the granting of this permit. ^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCEREGULA IN l'1^ Y L Re-roofs Si .to of Applican✓Cenommd, Data HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hvardmas maxdial in defined by the Cupertino Municipal,Code,Chapter 9.12,and the Health and Safely Code.Section 25532(%)? ❑Yes All roofs shall be inspected prior to any roofing material being installed. Will the applicant or ruwrc building Occupant use equipment ord,vias which If a roof is installed without first obtaining an inspection,I agree to remove It hulZWOus air contamimmis as dclincd by the Bay Arca Air Quality Management all new materials for inspection. isviet? O Y. 11NO I have mad the Icio rdnus materials dcyuimm nits under Chirac,6,95 of the Califor. nu Health K Safety Code,Satiou 25505.25533 and 2553%.l understand that if the tuilding does not currently have a tenant.that it is my responsibilily to notify the coeupaat of the reyuirlow7hfch fonstM mel pdocw issuance info certificate of Occupancy. $ignature of Applicant Date ./ _�1. � R2 16/03 All roof coverings to be Class "B" or better Own, Ib n,ad ogcnl Data g CITY OF CUPERTINO o v FURNACE/AC o 3 (2 UPERTINO PERMIT APPLICATION FORM APN # �/ D� O �� Date: Building Address: Owner's Name: A, ffif Contractor: NT PhoPlo ( Contact: Phone: Cupertino Business License #: Building Permit Info: Bldg ❑ Elect ❑ Plumb ❑ Mech Job Description: A Residential Commel ial ❑ For Residential Installations: Attic ❑ 151 floor ❑ 2"a floor❑ Adhere to min set back requirement❑ ForCommercial Installations: Replacement same weight ❑ Additional weight (structural calcs) ❑ Structural Calculations required for new installation ❑ New install ion Planning Ai)i)wval Required ❑ Cost ofcT . nst ction: Occup y gr p. r� �4 �A2 Strapped ❑ On Platform ❑ 7 Bonded ❑ Sq.Ft. Floor New Location ❑ Replacement ❑ Qty. if A i e Fee ID Fee Description Fee Group BENERGY Energy BUILDING BREMFURN Relocation of Furnace MECHANICAL BREMACOVER A/C Unit > 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL BSEISMICRE Seismic Fee Res BUILDING BSEISMICOM Seismic Commercial BUILIDNG EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPLANCHK Plan Check Fee BUILDING BUSLIC Business Licens BUILDING �� 0